Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement for Severe Aortic Stenosis in Patients With Chronic Kidney Disease Stages 3b to 5

Key Points Transcatheter aortic valve replacement (TAVR) seems superior to surgical aortic valve replacement (SAVR) for intermediate‐term outcomes in patients with aortic stenosis and moderate to severe chronic kidney disease (CKD). Intermediate‐term mortality and the major adverse cardiac and renal event increase if the renal function worsens soon after TAVR or SAVR. Patient's demographic profile, comorbid conditions, and procedural characteristics influence the clinical outcomes emphasizing the need for careful risk assessment in deciding TAVR versus SAVR in CKD patient.

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confidence: 99%

“…This study concludes that when the operative risk is not prohibitive, SAVR is an excellent choice in patients with advanced kidney disease. As these were not prospective randomized studies, they were only hypothesis generating rather than a proof …”

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confidence: 99%

Transcatheter aortic valve replacement: Protect the kidneys to protect the patient

Kumar

Seth

2019

“…Our search identified 14 observational comparative studies of TAVI versus SAVR using a propensity‐score analysis and reporting ≥3‐year all‐cause mortality, which enrolled a total of 4,197 patients (Tables and ). A study by D'Errigo et al exclusively included patients with chronic kidney disease stages of 3b to 5. A study by Rosato et al exclusively enrolled low‐risk patients with EuroSCORE II of <4%.…”

Section: Resultsmentioning

confidence: 99%

“…Of the 14 studies, 6 studies , 6 studies , and 2 studies indicated, respectively, a statistically significant benefit , a statistically nonsignificant benefit , and a statistically nonsignificant disadvantage of SAVR over TAVI for ≥3‐year mortality. A pooled analysis of all the 14 studies demonstrated a statistically significant 54% increase in mortality with TAVI relative to SAVR (primary meta‐analysis; HR, 1.54; 95% CI, 1.31–1.81; P for effect < 0.00001; P for heterogeneity = 0.14; I 2 = 30%; Figure ).…”

Section: Resultsmentioning

confidence: 99%

“…To assess the impact of qualitative heterogeneity in study design and patient selection on the pooled effect estimate, we performed several sensitivity analyses (Figures and , Table , Supporting Information Figures S1–S9). Sequentially excluding a study exclusively enrolling patients with chronic kidney disease stages of 3b to 5 (Sensitivity analysis 1, Supporting Information Figure S1), a study exclusively including low‐risk patients with EuroSCORE II of <4% (Sensitivity analysis 2, Supporting Information Figure S2), and a study exclusively enrolling patients undergoing sutureless SAVR as a surgical arm (Sensitivity analysis 3, Supporting Information Figure S3) from the primary meta‐analysis and combining the remaining 13 studies did not substantially change the statistically significant benefit for SAVR. In general, eliminating any single study from the primary meta‐analysis did not substantively alter the statistically significant result favoring SAVR (leave‐one‐out meta‐analysis; Figure ).…”

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Long‐term survival after transcatheter versus surgical aortic valve replacement for aortic stenosis: A meta‐analysis of observational comparative studies with a propensity‐score analysis

Takagi

Mitta

Ando

2018

Clinical impact of baseline chronic kidney disease in patients undergoing transcatheter or surgical aortic valve replacement

Pineda

Harrison

Kleiman

et al. 2018

Objectives To assess the treatment effect of TAVR versus SAVR on clinical outcomes to 3 years in patients stratified by chronic kidney disease (CKD) by retrospectively studying patients randomized to TAVR or SAVR. Background The impact of CKD on mid‐term outcomes of patients undergoing TAVR versus SAVR is unclear. Methods Patients randomized to TAVR or SAVR in the CoreValve US Pivotal High Risk Trial were retrospectively stratified by eGFR: none/mild or moderate/severe CKD. To evaluate the impact of baseline CKD in TAVR patients only, all patients undergoing an attempted TAVR implant in the US Pivotal Trial and CAS were stratified by baseline eGFR into none/mild, moderate, and severe CKD. The primary endpoint was major adverse cardiovascular and renal events (MACRE), a composite of all‐cause mortality, myocardial infarction, stroke/TIA, and new requirement of dialysis. Results Moderate/severe CKD was present in 62.7% and 60.7% of high‐risk patients randomized to TAVR or SAVR, respectively. Baseline characteristics were similar between TAVR and SAVR patients in both CKD subgroups, except for higher rates of diabetes and higher serum creatinine in SAVR patients. Among high‐risk patients with moderate/severe CKD, TAVR provided a lower 3‐year MACRE rate compared with SAVR: 42.1% vs. 51.0, P = .04. Of 3,733 extreme‐ and high‐risk TAVR patients, 39.9% had none/mild, 53.8% moderate, and 6.4% severe CKD. Worsening baseline CKD was associated with increased 3‐year MACRE rates [none/mild 51.5%, moderate 54.5%, severe 63.1%, P = .001]. Conclusions TAVR results in lower 3‐year MACRE versus SAVR in high‐risk patients with moderate/severe CKD. In patients undergoing TAVR, worsening CKD increases mid‐term mortality and MACRE. Randomized trials of TAVR vs. SAVR in patients with moderate‐severe CKD would help elucidate the best treatment for these complex patients. Trial Registration CoreValve US Pivotal Trial: NCT01240902. CoreValve Continued Access Study: NCT01531374.